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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600997
Report Date: 10/03/2024
Date Signed: 10/03/2024 03:01:37 PM

Document Has Been Signed on 10/03/2024 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:ST. ANTHONY'S HOMEFACILITY NUMBER:
415600997
ADMINISTRATOR/
DIRECTOR:		KAILA BRANCHFACILITY TYPE:
734
ADDRESS:3250 CRESTMOOR DRIVETELEPHONE:
(650) 742-1058
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Marivec Cruz, Luz Canares, Kaila Branch, Rizzi BuiTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards are observed. There are 4 private bedrooms for residents and 2 common bathrooms. There is a 2 car garage used for storage and wood deck in the backyard. Washer and dryer are located in hallway.
A comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink, including reminder signs to wash hands. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. Three residents receive g-tube feeding; 7-day supply of formulas are maintained. Food supply for one resident is observed. There are 2 residents present, and 2 staff. Client records are reviewed and criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as required staff records. Kaila Branch is the administrator (x 4/25) that oversees facility operations.

The following form is provided to LPA today:
• LIC 610D Emergency Disaster Plan

The following forms/information are requested to be submitted to CCLD by 10/17/24:
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 400 Affidavit Regarding Client Cash Resources
• Proof of current surety bonding

Deficiency of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, Chapter 1, Articles 1-7 is observed and cited on a following page.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 03:01 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/03/2024 at 01:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ST. ANTHONY'S HOME
FACILITY NUMBER: 415600997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80019(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 80019(f) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above in 1 out of 6 staff files reviewed, which poses an immediate health, safety or personal rights risk to persons in care.
- Staff #3 is present at facility as a direct service provider, but does not have criminal record clearance and association with facility. His criminal record clearance has not been transferred to this facility, and he has been employed since 2022
POC Due Date: 10/03/2024
Plan of Correction
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Criminal Background Clearance Transfer Request for S3 is given to LPA today with photo ID.
Deficiency corrected and cleared
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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